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Late Results of Palmar Arch Bypass in the Treatment of Digital Trophic Disorders
Late Results of Palmar Arch Bypass in the Treatment of Digital Trophic Disorders Xavier Barral, MD, Jean Pierre Favre, MD, Jean Paul Gournier, MD, Michel Farcot, MD, Sylvie Cambou, MD, Saint-Etienne, France
This study reports the late results of eight palmar bypass procedures performed between 1983 and 1988 in eight men patients with a mean age of 43 years old, who presented with unilateral digital trophic disorders. The origin of the arterial lesions was post-traumatic in four cases, embolic in three cases, and aneurysma! in one. The procedures performed included four radiopalmar bypasses, two ulnar-palmar bypasses, one distal radial bypass and one palmopalmar bypass. In all cases, the replacement conduit used was the superficial radial vein retrieved from the wrist. There were no complications observed in this short series. All fingers healed within three weeks' time after excision of necrotic lesions. During a mean follow-up of 66 months, two bypasses became thrombosed, leading to amputation of the distal phalanx of a thumb in one patient while the remaining six bypasses remained patent, three of them for more than seven years. In the presence of trophic changes of the fingers, palmar arch bypasses, whenever feasible, are more effective at long-term and less aggressive than the usually proposed thoracic sympathectomy. (Ann Vasc Surg 1992; 6:418-424). KEY WORDS: Palmar arteries; bypass; hand surgery; digital ischemia; peripheral vascular disease.
Vascular surgery of the upper limb has classically been limited to proximal reconstructions [I--4] while thoracic sympathectomy was used for distal lesions. Thoracic sympathectomy, however, is inappropriate in some instances, particularly in the case of severe distal ischemia which is only curable by peripheral reconstruction. These primary vascular reconstructions, the equivalent of malleolar reconstructions in the lower limbs, form the basis of this study.
From the Service de Chirurgie Vasculaire, Centre Hospitalier et Universitaire, Saint-Etienne, France. Presented at the Annual Meeting of the SociOt~ de Chirurgie Vasculaire de Langue Franfaise, May 18-19, 1990, Nancy, France. Reprint requests: X. Barral, MD, Service de Chirurgie Vasculaire, HOpital Nord, CHU de Saint-Etienne, 42270 Saint Priest en Jarez, France.
PATIENTS AND METHODS Between January l, 1983 and January l, 1988, eight patients underwent a palmar arch bypass. The principal patient characteristics are listed in Table I. All patients were male. Their ages ranged from 29 to 60 years old, the mean being 43. Six of the eight patients were smokers. Patients sought medical attention for distal gangrene of one finger in two cases and of several fingers in three cases. The three other patients presented with minor equivalents of necrosis including false panaris, ischemic chap, and blue finger in an acute ischemia setting. Diagnostic work-up included capillaroscopy and biological investigations, whose goal was to exclude the diagnosis of connective tissue disease. Plethysmography showed a flat or markedly demodulated curve in all cases. Traditional or digital subtraction arteriograms were performed according to Seld-
418
Uneventful Uneventful
Radioulnar bypass Radioulnar bypass
Radioulnar bypass Distal ulnar bypass Distal radial bypass Radiopalmar bypass
Thrombosis of arch digital arteritis Radial and ulnar artery thrombosis Interosseous artery thrombosis Radial and ulnar artery thrombosis Distal lesions Radial and ulnar artery embolism Radial and ulnar artery thrombosis Radial artery embolism
Necrosis pulp 1st finger ischemia of hand
Necrosis pulp 3rd, 4th and 5th fingers "Blue finger syndrome" of 2nd finger Necrosis pulp 4th and 5th fingers Necrotic "chap" 2nd finger
M
M
M
M
M
M
32
60
41
37
62
5O
3
4
5
6
7
8
Amput~ion 2nd phalanx 2nd finger
Uneventful
Uneventful
Uneventful
Uneventful
Distal ulnar bypass
Radial and ulnar artery embolism
Necrosis pulp 2nd and 3rd fingers "False panaris" 2nd finger
M
34
2
Immediate outcome Uneventful
Operation Palmar arch
Lesions Palmar arch aneurysm with distal embolism
Symptoms Necrosis pulp 2nd finger
Sex M
Age 29
Patient 1
TABLE I.--Clinical characteristics of the eight patients Follow-up 8 years patent asymptomatic 7 years patent asymptomatic 7 years patent asymptomatic 6 years thrombosis at one year: repeat operation: failure distal amputation I finger 5 years thrombosed asymptomatic 4 years patent asymptomatic 3.5 years patent asymptomatic 3.5 years patent asymptomatic
t~
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ANNALS OF VASCULAR SURGERY
PALMAR ARCH BYPASS
420
inger's technique via the femoral route and subclavian catheterization. No other proximal abnormalities (such as, stenosis of the subclavian artery, thoracic outlet syndrome or aneurysm) were evidenced. In seven cases, both distal radial and ulnar arteries were involved. Long-standing embolism was the cause in three cases, while thrombosis of pathological or post-traumatic arteries were the cause in four others. One patient had dysplastic aneurysm of the palmar arch. Embolism was diagnosed in three instances because of a cupuloform image in patients with known emboligenic cardiac disease, whereas in four instances, the diagnosis was thrombosis because of diffuse and irregular lesions with the notion of local trauma and hammer syndrome in three of four patients. Operation was carried out under general anesthesia in three cases while plexic block anesthesia was employed in five. The surgical approach varied according to the lesions. Bypasses originating from the radial artery were made at the level of the anatomic snuffbox with a distal zigzag extension of the cutaneous incision as used to decompress carpal canal syndromes. The ulnar artery was approached in Guyon's canal. Palmar aneurysm was treated through an arciform incision centered on a palmar fold. All patients had local intraoperative heparin. The procedures performed were four radiopalmar bypasses, two ulnarpalmar bypasses, one distal radial bypass and one palmopalmar bypass. The superficial radial vein (length ranging from 2 to 5 cm) was retrieved from the forearm and used for replacement in all cases. The anastomoses were performed with the magnification loupe using 8/0 monofilament suture material. Completion arteriograms were obtained in all cases. Gangrene and necrosis were excised and cleaned during the same operation. All patients had subcutaneous heparin for 15 days. All patients received platelet antiaggregation medication (Ticlopidine) for three months. The duration of hospital stay never exceeded 48 hours. Surveillance and postoperative follow-up investigations and clinical examinations were performed on an ambulatory basis.
RESULTS All patients were followed regularly. Mean follow-up was 66 months. No early complications occurred. All wounds healed progressively within an average of three months' time without any further procedures being necessary. One patient underwent an initial amputation of the second phalanx of his index finger because of irreversible ischemia with mummification of the pulp. This patient had severe ischemia of his entire index finger and the palmar arch bypass made it possible to preserve a partial pinch.
Doppler, plethysmographic, and arteriographic follow-up investigations were performed at three months and showed that all the bypasses were patent. Two bypasses became thrombosed later on. One thrombosis occurred at one year with reappearance of distal trophic disorders. Repeat bypass was attempted without success due to degradation of the distal arterial bed, and finger amputation became necessary. The bypass occluded in another patient, who had few remaining symptoms, with residual Raynaud's phenomenon related to cold, without new necrosis. This patient did not undergo repeat operation. Three bypasses have remained patent with more than seven years follow-up.
DISCUSSION In our experience palmar bypasses represent only 8% of the total of vascular reconstructive procedures performed in the upper limb. Our analysis of the literature has confirmed the occasional character of this type of surgery. Most of the articles on the subject have been published in hand, orthopedic, or reconstructive surgery journals rather than in vascular surgery journals [5-11]. Overall, including the present series, only 40 cases have been reported to date. Three reasons may be advanced to explain this rarity. The main reason is the extreme richness of the arterial anastomotic system in the hand [12]. The epithelial surface of the fingers is 6.25 times greater than that of the other cutaneous territories. For this, a tiered arterial system with two palmar arches provides an excellent quality of perfusion to the hand. The direction of blood flow can in fact be either radial to ulnar or ulnar to radial [12]. Because of the quality of this collaterality, the risk of necrosis is small. Severe ischemia will occur only when (1) distal occlusion involves both digital arteries; (2) proximal occlusion involves both the radial and ulnar arteries, associated with poor coUaterality; (3) proximal occlusion of either the radial or the ulnar artery occurs alone but with a nonfunctional palmar arch; or (4) double palmar and collateral occlusion occurs simultaneously (Fig. 1). In their study of 650 cadaver palmar arches, Coleman and Anson [13] found that 21.5% were not functional, and in these cases, there was no arterial connection between the radial and ulnar arteries. In such case, segmental occlusion of one or the other arteries is poorly compensated, if at all, by the contralateral vessel. The small number of patients requiring surgical intervention for palmar bypass may be explained by the rarity of atheroma in the palmar arch, which is susceptible of compromising the collateral network and provoking severe ischemia. In most cases, post-traumatic or post-embolic segmental occlu-
VOLUME 6 NO 5 - 1992
P A L M A R A R C H BYPASS
Fig. 1. Lesions of palmar and digital arteries that were responsible for digital gangrene,
sions have been responsible for limited lesions without distal involvement [14]. In these case, the collateral network is not compromised and can take over the circulation once the acute episode is over. Most often, ischemia of the hand due to distal arterial lesions of the upper limb responds well to medical treatment [15] or thoracic sympathectomy. Because of the satisfactory results obtained by these two methods, vascular surgeons have not been interested in developing reconstruction techniques in this area. In line with Given and associates [5], however, we do not share this optimistic thinking. Four of our patients were referred to us after failure of thoracic sympathectomy associated with traditional medical treatment. In all four cases, palmar arch reconstruction ensured rapid healing of lesions which had been chronically open for months. In our opinion, three factors seem to be important before performing a palmar arch bypass. Clinical findings are the mainstay in the determination of therapeutic policy. Superficial necrosis of the finger pulp or painful ischemia usually responds well to medical treatment or thoracic sympathectomy. This
421
contrasts with deeper lesions with true gangrene of one or several phalanges. Even if mummification with clear demarcation of healthy and necrotic tissues occurs, amputation is not always followed by definitive healing. In our opinion, chronic wounds associated with painful amputation stumps should be revascularized. Allen's maneuver can establish the arterial pattern of the hand. This maneuver will readily differentiate distal occlusions from nonfunctional palmar arches and proximal involvement. Thus, without the need for sophisticated investigations, this simple test will inform the surgeon, right from the first consultation, of the exact location of the disorder and whether or not it is surgically curable. Digital plethysmography completes Allen's test by showing whether distal vascularization is pulsed or not. A flat or demodulated curve should lead to revascularization. Certain surgical teams associate digital thermography and dynamic thermometry. We have abandoned this technique because we feel that it does not provide any complementary information about the hemodynamics. Measurement of digital cutaneous TcpO2 in the involved digits, on the other hand, seems to be more fruitful. Revascularization should be attempted when the TcpO2 is less than 20 mmHg. Etiological workup must eliminate trophic disorders related to inflammatory or connective tissue disease. Even if this type of pathology is occasionally associated with surgically curable arterial disease, microcirculation involvement is constant and constitutes a major risk for early failure of revascularization. The same holds true for rheological disorders induced by polycythemia or hyperthrombocytemia, which are not compatible with these delicate and small bypasses. In our experience, aside from palmar arch aneurysm, the indications for surgery include atheroma, embolism, and trauma. The rare emboligenic subclavian aneurysms that we have operated on were responsible for acute ischemia due to occlusion of the distal brachial artery bifurcation. The thoracic outlet syndrome, which can be responsible for Raynaud's syndrome and give rise to distal microembolism was not encountered in this series. All of our patients had emboligenic heart disease. As regards the hypothenar hammer syndrome or traumatic thrombosis of the ulnar artery, described by Von Rosen in 1934 [16], Mathews and Gould [10] reviewed 19 publications advocating arteriectomy as the treatment of choice for this syndrome. Further scrutiny of these observations, however, showed that arteriectomy was associated with satisfactory results as concerns the pain in the hypothenar eminence. The substratum for pain, however, is neurogenic and not ischemic. After thrombosis, perivascular inflammation appears, as may be seen
422
PALMAR ARCH BYPASS
intraoperatively, and this constitutes an irritative factor for the adjacent nerve structures [17]. This hypothesis may be attested to by the frequently positive Tinel's sign at the level of Guyon's canal. In reality, arteriectomy has the effect of neurolysis, which is effective for pain. The patients are relieved due to the simple fact that blood circulates in their palmar arch. The vasodilatative effect of arteriectomy, on the other hand, does not treat the digital trophic disorder. Arteriectomy does not afford any relief in itself and should always be associated with vascular reconstruction by a vein graft. This is the only way to obtain rapid healing of the trophic disorders and to avoid incomplete results as seen in the residual Raynaud's syndrome [5] without increasing the operative risk. Arteriograms constitute the last element in the indications for operation, In our opinion, direct puncture of the brachial artery at the level of the elbow seems inadequate because the subclavian artery is not well visualized and this method is associated with spasms. Even when vasodilatator medication is given, the images obtained may not be satisfactory. Like Pineda and colleagues [18], we prefer to perform selective catheterization of the subclavian artery via the femoral artery, and to obtain two series of films, with and without injection of vasodilatory drugs. The indication for surgery is straightforward when both the radial and ulnar arteries are occluded at the level of the wrist with good palmar reinjection (Fig. 2). In the rare instances of acute ischemia due to trauma or vessel puncture, the palmar arch will not be visualized, as observed in one of our cases. A direct approach to the palmar arch and intraoperative arteriograms are necessary to guide reconstruction. Arteriograms can show segmental occlusion of the termination of the radial and ulnar arteries associated with an absent or pathological palmar arch. Arteriograms can show double tier lesions at the level of the digital collateral arteries and the palmar arch. In this case, our therapeutic policy is guided by plethysmographic findings and percutaneous TcpO 2 measurement. When these investigations are only modestly pathological, we advocate medical treatment or sympathectomy. In the case of unfavorable results, we envisage reconstruction whenever arteriograms are of sufficient quality to document the distal segment best suited to receive the distal anastomosis. Even though palmar bypass may be considered a " m i n o r " procedure, we do not perform this operation under local anesthesia. Under xyiocaine, hemorrhagic oozing might hinder the surgeon. The plexic nerve blocks are, on the other hand, very useful in this type of surgery, because they associate comfort and vasodilatation. In case of contrain-
ANNALS OF VASCULAR SURGERY
Fig. 2. Postoperative arteriogram showing patency of radiopalmar bypass for hand ischemia due to occlusive disease of the radial, ulnar, and interosseous arteries.
dications to regional anesthesia, general anesthesia is used. Aside from the minute character of the dissection and anastomosis in this type of surgery, the operation itself does not present any particular problems. The surgical approaches described above are the traditional surgical approaches used in ordinary hand surgery. Magnification is mandatory. The superficial radial vein constitutes the graft material of choice, even when its caliber is occasionally larger than that of the arteries to be bypassed (Fig. 3). This does not seem to be a problem at long-term. Intraoperatively, spasms related to local manipulations of the vessels may occur. This may be treated by mechanical dilatation, and when the arteries to be anastomosed are unclamped, by swabbing them with adalate and papaverine solutions. In our opinion, postoperative heparin should be employed because the size of the anastomosis is generally no more than 2 mm. As observed in the literature, no postoperative complications were observed in this short series. Thrombosis occurred in two patients but only one had repeat trophic disorders.
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a
423
b
Fig. 3. (a) Aneurysm of distal ulnar ~.and palmar arch causing digital necrosis. (b) Postoperative arteriogram showing patency of ulnoulnar arteuypass.
Aside from the excellent quality of results, the absence of morbidity constitutes a strong argument in favor of this type of surgery. This is not the case with thoracic sympathectomy. Even when sympathectomy is performed through the supraclavicular route, Horner's syndrome, pneumothorax, or contralateral secondary sympathetic hyperactivity are possible complications which are particularly difficult to manage.
CONCLUSION Palmar arch bypass is a nonaggressive operation. The local and general risks, as well as the technical difficulties, are similar to those encountered in the surgical construction of radial arteriovenous fistula for dialysis access in kidney failure. This type of surgery should be familiar to all vascular surgeons, especially those who are familiar with the techniques of radial arteriovenous fistula for hemodialysis. Results are remarkably satisfactory and re-
main so with time. Presently, in the event of digital gangrene, we believe that palmar arch reconstruction should be proposed initially, whenever local and arterial conditions are favorable.
REFERENCES 1. WHITEHOUSE WM, ZELENOCK GB, WAKEFIELD TW, et al. Arterial bypass grafts for upper extremity ischemia. J Vast: Surg 1986;3:569-573. 2. M C C A R T H Y WJ, FLINN WR, YAO JST, et al. Result of bypass grafting for upper limb ischemia. J Vasc Surg 1986; 3:741-745. 3. SCHWARTZ RA. MANTESE V, PALETTA CH, et al. Upper extremity limb salvage accomplished by in situ vein bypass graft, Ann Vasc Surg 1988:2:309-314, 4. MACHLEDER HI, W H E E L E R E, BARKER WF. Treatment of upper extremity ischemia by cervicodorsal sympathectomy. Vasc Surg 1979;13:399--402. 5. GIVEN KS. PUCKETT CL, KLEINERT HE. Ulnar artery thrombosis. Plast Reconstr Surg 1978;61:405--411. 6. GOULD JS, GOULD SH, CAUDILL-BABKES EL, Interpositional microvascular vein grafting. Hand 1979;11:332336.
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PALMAR ARCH BYPASS
7. KUSTER LV. ABT A. Traumatic aneurysm of the ulnar artery. Arch Pathol Lab Med 1980;104:75-78. 8. KOMAN LA, URBANIAK JR. Ulnar artery insufficiency: a guide treatment. J Hand Surg 1981:6:16-24. 9. SILCOTT GR, POLICH VL. Palmar arch arterial reconstruction for the salvage of ischemic fingers. Am J Surg 198t;142:219-225. 10, MATHEWS RE, GOULD JS. Thrombosis of the ulnar artery resection and microvascular vein graft, Hand 1983; •5:85-90. 11. CAFFEE HH. MASLER NT. Atherosclerosis of the forearm and hand. J Hand Surg 1984;9A: 193-196, 12, BARREIRO FJ, VALDECASAS MG, Etude h I'aide de la radioanatomie de la vascularisation de l'avant-bras el de la main: acquisitions r6centes. In: TUBIANA R (edL Chirurgie de la Main, Paris, Masson, 1980, pp 332-349.
nun
ANNALS OF VASCULARSURGERY
13. COLEMAN SS, ANSON BJ. Arterial patterns in the hand based upon a study of 650 specimens. Surg Gynecol Obstet 1961:113:409-424. 14. LAURIAN C. Traumatismes arteriels de la main. EMC, 1990, Techiques Chirurgicales, Chirurgie Vasculaire 43027. 15. VAYSSAIRAT M, DEBURE C, CORMIER JM, et al. Hypothenar hammer syndrome: seventeen cases with long term follow up. J Vasc Surg 1987:6:838-843. 16. VON ROSEN S. Ein fall yon thrombose in der arteria ulnaris nach einwizkung von stumpfer gevalt. Acta Chir Scand 1934;73:500-506, 17. HERNDON W, HERSHEY S, LAMBDIN C. Thrombosis of the ulnar artery in the hand. JBJS 1975;57 A:994-995. 18. PINEDA CJ, WEISMAN MH, BOOKSTEIN JJ, et al. Hypothenar hammar syndrome: forms of reversible Raynaud's phenomenon. Am J Med 1985;79:561-570.
This study reports the late results of eight palmar bypass procedures performed between 1983 and 1988 in eight men patients with a mean age of 43 years old, who presented with unilateral digital trophic disorders. The origin of the arterial lesions was post-traumatic in four cases, embolic in three cases, and aneurysma! in one. The procedures performed included four radiopalmar bypasses, two ulnar-palmar bypasses, one distal radial bypass and one palmopalmar bypass. In all cases, the replacement conduit used was the superficial radial vein retrieved from the wrist. There were no complications observed in this short series. All fingers healed within three weeks' time after excision of necrotic lesions. During a mean follow-up of 66 months, two bypasses became thrombosed, leading to amputation of the distal phalanx of a thumb in one patient while the remaining six bypasses remained patent, three of them for more than seven years. In the presence of trophic changes of the fingers, palmar arch bypasses, whenever feasible, are more effective at long-term and less aggressive than the usually proposed thoracic sympathectomy. (Ann Vasc Surg 1992; 6:418-424). KEY WORDS: Palmar arteries; bypass; hand surgery; digital ischemia; peripheral vascular disease.
Vascular surgery of the upper limb has classically been limited to proximal reconstructions [I--4] while thoracic sympathectomy was used for distal lesions. Thoracic sympathectomy, however, is inappropriate in some instances, particularly in the case of severe distal ischemia which is only curable by peripheral reconstruction. These primary vascular reconstructions, the equivalent of malleolar reconstructions in the lower limbs, form the basis of this study.
From the Service de Chirurgie Vasculaire, Centre Hospitalier et Universitaire, Saint-Etienne, France. Presented at the Annual Meeting of the SociOt~ de Chirurgie Vasculaire de Langue Franfaise, May 18-19, 1990, Nancy, France. Reprint requests: X. Barral, MD, Service de Chirurgie Vasculaire, HOpital Nord, CHU de Saint-Etienne, 42270 Saint Priest en Jarez, France.
PATIENTS AND METHODS Between January l, 1983 and January l, 1988, eight patients underwent a palmar arch bypass. The principal patient characteristics are listed in Table I. All patients were male. Their ages ranged from 29 to 60 years old, the mean being 43. Six of the eight patients were smokers. Patients sought medical attention for distal gangrene of one finger in two cases and of several fingers in three cases. The three other patients presented with minor equivalents of necrosis including false panaris, ischemic chap, and blue finger in an acute ischemia setting. Diagnostic work-up included capillaroscopy and biological investigations, whose goal was to exclude the diagnosis of connective tissue disease. Plethysmography showed a flat or markedly demodulated curve in all cases. Traditional or digital subtraction arteriograms were performed according to Seld-
418
Uneventful Uneventful
Radioulnar bypass Radioulnar bypass
Radioulnar bypass Distal ulnar bypass Distal radial bypass Radiopalmar bypass
Thrombosis of arch digital arteritis Radial and ulnar artery thrombosis Interosseous artery thrombosis Radial and ulnar artery thrombosis Distal lesions Radial and ulnar artery embolism Radial and ulnar artery thrombosis Radial artery embolism
Necrosis pulp 1st finger ischemia of hand
Necrosis pulp 3rd, 4th and 5th fingers "Blue finger syndrome" of 2nd finger Necrosis pulp 4th and 5th fingers Necrotic "chap" 2nd finger
M
M
M
M
M
M
32
60
41
37
62
5O
3
4
5
6
7
8
Amput~ion 2nd phalanx 2nd finger
Uneventful
Uneventful
Uneventful
Uneventful
Distal ulnar bypass
Radial and ulnar artery embolism
Necrosis pulp 2nd and 3rd fingers "False panaris" 2nd finger
M
34
2
Immediate outcome Uneventful
Operation Palmar arch
Lesions Palmar arch aneurysm with distal embolism
Symptoms Necrosis pulp 2nd finger
Sex M
Age 29
Patient 1
TABLE I.--Clinical characteristics of the eight patients Follow-up 8 years patent asymptomatic 7 years patent asymptomatic 7 years patent asymptomatic 6 years thrombosis at one year: repeat operation: failure distal amputation I finger 5 years thrombosed asymptomatic 4 years patent asymptomatic 3.5 years patent asymptomatic 3.5 years patent asymptomatic
t~
4~
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ANNALS OF VASCULAR SURGERY
PALMAR ARCH BYPASS
420
inger's technique via the femoral route and subclavian catheterization. No other proximal abnormalities (such as, stenosis of the subclavian artery, thoracic outlet syndrome or aneurysm) were evidenced. In seven cases, both distal radial and ulnar arteries were involved. Long-standing embolism was the cause in three cases, while thrombosis of pathological or post-traumatic arteries were the cause in four others. One patient had dysplastic aneurysm of the palmar arch. Embolism was diagnosed in three instances because of a cupuloform image in patients with known emboligenic cardiac disease, whereas in four instances, the diagnosis was thrombosis because of diffuse and irregular lesions with the notion of local trauma and hammer syndrome in three of four patients. Operation was carried out under general anesthesia in three cases while plexic block anesthesia was employed in five. The surgical approach varied according to the lesions. Bypasses originating from the radial artery were made at the level of the anatomic snuffbox with a distal zigzag extension of the cutaneous incision as used to decompress carpal canal syndromes. The ulnar artery was approached in Guyon's canal. Palmar aneurysm was treated through an arciform incision centered on a palmar fold. All patients had local intraoperative heparin. The procedures performed were four radiopalmar bypasses, two ulnarpalmar bypasses, one distal radial bypass and one palmopalmar bypass. The superficial radial vein (length ranging from 2 to 5 cm) was retrieved from the forearm and used for replacement in all cases. The anastomoses were performed with the magnification loupe using 8/0 monofilament suture material. Completion arteriograms were obtained in all cases. Gangrene and necrosis were excised and cleaned during the same operation. All patients had subcutaneous heparin for 15 days. All patients received platelet antiaggregation medication (Ticlopidine) for three months. The duration of hospital stay never exceeded 48 hours. Surveillance and postoperative follow-up investigations and clinical examinations were performed on an ambulatory basis.
RESULTS All patients were followed regularly. Mean follow-up was 66 months. No early complications occurred. All wounds healed progressively within an average of three months' time without any further procedures being necessary. One patient underwent an initial amputation of the second phalanx of his index finger because of irreversible ischemia with mummification of the pulp. This patient had severe ischemia of his entire index finger and the palmar arch bypass made it possible to preserve a partial pinch.
Doppler, plethysmographic, and arteriographic follow-up investigations were performed at three months and showed that all the bypasses were patent. Two bypasses became thrombosed later on. One thrombosis occurred at one year with reappearance of distal trophic disorders. Repeat bypass was attempted without success due to degradation of the distal arterial bed, and finger amputation became necessary. The bypass occluded in another patient, who had few remaining symptoms, with residual Raynaud's phenomenon related to cold, without new necrosis. This patient did not undergo repeat operation. Three bypasses have remained patent with more than seven years follow-up.
DISCUSSION In our experience palmar bypasses represent only 8% of the total of vascular reconstructive procedures performed in the upper limb. Our analysis of the literature has confirmed the occasional character of this type of surgery. Most of the articles on the subject have been published in hand, orthopedic, or reconstructive surgery journals rather than in vascular surgery journals [5-11]. Overall, including the present series, only 40 cases have been reported to date. Three reasons may be advanced to explain this rarity. The main reason is the extreme richness of the arterial anastomotic system in the hand [12]. The epithelial surface of the fingers is 6.25 times greater than that of the other cutaneous territories. For this, a tiered arterial system with two palmar arches provides an excellent quality of perfusion to the hand. The direction of blood flow can in fact be either radial to ulnar or ulnar to radial [12]. Because of the quality of this collaterality, the risk of necrosis is small. Severe ischemia will occur only when (1) distal occlusion involves both digital arteries; (2) proximal occlusion involves both the radial and ulnar arteries, associated with poor coUaterality; (3) proximal occlusion of either the radial or the ulnar artery occurs alone but with a nonfunctional palmar arch; or (4) double palmar and collateral occlusion occurs simultaneously (Fig. 1). In their study of 650 cadaver palmar arches, Coleman and Anson [13] found that 21.5% were not functional, and in these cases, there was no arterial connection between the radial and ulnar arteries. In such case, segmental occlusion of one or the other arteries is poorly compensated, if at all, by the contralateral vessel. The small number of patients requiring surgical intervention for palmar bypass may be explained by the rarity of atheroma in the palmar arch, which is susceptible of compromising the collateral network and provoking severe ischemia. In most cases, post-traumatic or post-embolic segmental occlu-
VOLUME 6 NO 5 - 1992
P A L M A R A R C H BYPASS
Fig. 1. Lesions of palmar and digital arteries that were responsible for digital gangrene,
sions have been responsible for limited lesions without distal involvement [14]. In these case, the collateral network is not compromised and can take over the circulation once the acute episode is over. Most often, ischemia of the hand due to distal arterial lesions of the upper limb responds well to medical treatment [15] or thoracic sympathectomy. Because of the satisfactory results obtained by these two methods, vascular surgeons have not been interested in developing reconstruction techniques in this area. In line with Given and associates [5], however, we do not share this optimistic thinking. Four of our patients were referred to us after failure of thoracic sympathectomy associated with traditional medical treatment. In all four cases, palmar arch reconstruction ensured rapid healing of lesions which had been chronically open for months. In our opinion, three factors seem to be important before performing a palmar arch bypass. Clinical findings are the mainstay in the determination of therapeutic policy. Superficial necrosis of the finger pulp or painful ischemia usually responds well to medical treatment or thoracic sympathectomy. This
421
contrasts with deeper lesions with true gangrene of one or several phalanges. Even if mummification with clear demarcation of healthy and necrotic tissues occurs, amputation is not always followed by definitive healing. In our opinion, chronic wounds associated with painful amputation stumps should be revascularized. Allen's maneuver can establish the arterial pattern of the hand. This maneuver will readily differentiate distal occlusions from nonfunctional palmar arches and proximal involvement. Thus, without the need for sophisticated investigations, this simple test will inform the surgeon, right from the first consultation, of the exact location of the disorder and whether or not it is surgically curable. Digital plethysmography completes Allen's test by showing whether distal vascularization is pulsed or not. A flat or demodulated curve should lead to revascularization. Certain surgical teams associate digital thermography and dynamic thermometry. We have abandoned this technique because we feel that it does not provide any complementary information about the hemodynamics. Measurement of digital cutaneous TcpO2 in the involved digits, on the other hand, seems to be more fruitful. Revascularization should be attempted when the TcpO2 is less than 20 mmHg. Etiological workup must eliminate trophic disorders related to inflammatory or connective tissue disease. Even if this type of pathology is occasionally associated with surgically curable arterial disease, microcirculation involvement is constant and constitutes a major risk for early failure of revascularization. The same holds true for rheological disorders induced by polycythemia or hyperthrombocytemia, which are not compatible with these delicate and small bypasses. In our experience, aside from palmar arch aneurysm, the indications for surgery include atheroma, embolism, and trauma. The rare emboligenic subclavian aneurysms that we have operated on were responsible for acute ischemia due to occlusion of the distal brachial artery bifurcation. The thoracic outlet syndrome, which can be responsible for Raynaud's syndrome and give rise to distal microembolism was not encountered in this series. All of our patients had emboligenic heart disease. As regards the hypothenar hammer syndrome or traumatic thrombosis of the ulnar artery, described by Von Rosen in 1934 [16], Mathews and Gould [10] reviewed 19 publications advocating arteriectomy as the treatment of choice for this syndrome. Further scrutiny of these observations, however, showed that arteriectomy was associated with satisfactory results as concerns the pain in the hypothenar eminence. The substratum for pain, however, is neurogenic and not ischemic. After thrombosis, perivascular inflammation appears, as may be seen
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intraoperatively, and this constitutes an irritative factor for the adjacent nerve structures [17]. This hypothesis may be attested to by the frequently positive Tinel's sign at the level of Guyon's canal. In reality, arteriectomy has the effect of neurolysis, which is effective for pain. The patients are relieved due to the simple fact that blood circulates in their palmar arch. The vasodilatative effect of arteriectomy, on the other hand, does not treat the digital trophic disorder. Arteriectomy does not afford any relief in itself and should always be associated with vascular reconstruction by a vein graft. This is the only way to obtain rapid healing of the trophic disorders and to avoid incomplete results as seen in the residual Raynaud's syndrome [5] without increasing the operative risk. Arteriograms constitute the last element in the indications for operation, In our opinion, direct puncture of the brachial artery at the level of the elbow seems inadequate because the subclavian artery is not well visualized and this method is associated with spasms. Even when vasodilatator medication is given, the images obtained may not be satisfactory. Like Pineda and colleagues [18], we prefer to perform selective catheterization of the subclavian artery via the femoral artery, and to obtain two series of films, with and without injection of vasodilatory drugs. The indication for surgery is straightforward when both the radial and ulnar arteries are occluded at the level of the wrist with good palmar reinjection (Fig. 2). In the rare instances of acute ischemia due to trauma or vessel puncture, the palmar arch will not be visualized, as observed in one of our cases. A direct approach to the palmar arch and intraoperative arteriograms are necessary to guide reconstruction. Arteriograms can show segmental occlusion of the termination of the radial and ulnar arteries associated with an absent or pathological palmar arch. Arteriograms can show double tier lesions at the level of the digital collateral arteries and the palmar arch. In this case, our therapeutic policy is guided by plethysmographic findings and percutaneous TcpO 2 measurement. When these investigations are only modestly pathological, we advocate medical treatment or sympathectomy. In the case of unfavorable results, we envisage reconstruction whenever arteriograms are of sufficient quality to document the distal segment best suited to receive the distal anastomosis. Even though palmar bypass may be considered a " m i n o r " procedure, we do not perform this operation under local anesthesia. Under xyiocaine, hemorrhagic oozing might hinder the surgeon. The plexic nerve blocks are, on the other hand, very useful in this type of surgery, because they associate comfort and vasodilatation. In case of contrain-
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Fig. 2. Postoperative arteriogram showing patency of radiopalmar bypass for hand ischemia due to occlusive disease of the radial, ulnar, and interosseous arteries.
dications to regional anesthesia, general anesthesia is used. Aside from the minute character of the dissection and anastomosis in this type of surgery, the operation itself does not present any particular problems. The surgical approaches described above are the traditional surgical approaches used in ordinary hand surgery. Magnification is mandatory. The superficial radial vein constitutes the graft material of choice, even when its caliber is occasionally larger than that of the arteries to be bypassed (Fig. 3). This does not seem to be a problem at long-term. Intraoperatively, spasms related to local manipulations of the vessels may occur. This may be treated by mechanical dilatation, and when the arteries to be anastomosed are unclamped, by swabbing them with adalate and papaverine solutions. In our opinion, postoperative heparin should be employed because the size of the anastomosis is generally no more than 2 mm. As observed in the literature, no postoperative complications were observed in this short series. Thrombosis occurred in two patients but only one had repeat trophic disorders.
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Fig. 3. (a) Aneurysm of distal ulnar ~.and palmar arch causing digital necrosis. (b) Postoperative arteriogram showing patency of ulnoulnar arteuypass.
Aside from the excellent quality of results, the absence of morbidity constitutes a strong argument in favor of this type of surgery. This is not the case with thoracic sympathectomy. Even when sympathectomy is performed through the supraclavicular route, Horner's syndrome, pneumothorax, or contralateral secondary sympathetic hyperactivity are possible complications which are particularly difficult to manage.
CONCLUSION Palmar arch bypass is a nonaggressive operation. The local and general risks, as well as the technical difficulties, are similar to those encountered in the surgical construction of radial arteriovenous fistula for dialysis access in kidney failure. This type of surgery should be familiar to all vascular surgeons, especially those who are familiar with the techniques of radial arteriovenous fistula for hemodialysis. Results are remarkably satisfactory and re-
main so with time. Presently, in the event of digital gangrene, we believe that palmar arch reconstruction should be proposed initially, whenever local and arterial conditions are favorable.
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7. KUSTER LV. ABT A. Traumatic aneurysm of the ulnar artery. Arch Pathol Lab Med 1980;104:75-78. 8. KOMAN LA, URBANIAK JR. Ulnar artery insufficiency: a guide treatment. J Hand Surg 1981:6:16-24. 9. SILCOTT GR, POLICH VL. Palmar arch arterial reconstruction for the salvage of ischemic fingers. Am J Surg 198t;142:219-225. 10, MATHEWS RE, GOULD JS. Thrombosis of the ulnar artery resection and microvascular vein graft, Hand 1983; •5:85-90. 11. CAFFEE HH. MASLER NT. Atherosclerosis of the forearm and hand. J Hand Surg 1984;9A: 193-196, 12, BARREIRO FJ, VALDECASAS MG, Etude h I'aide de la radioanatomie de la vascularisation de l'avant-bras el de la main: acquisitions r6centes. In: TUBIANA R (edL Chirurgie de la Main, Paris, Masson, 1980, pp 332-349.
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13. COLEMAN SS, ANSON BJ. Arterial patterns in the hand based upon a study of 650 specimens. Surg Gynecol Obstet 1961:113:409-424. 14. LAURIAN C. Traumatismes arteriels de la main. EMC, 1990, Techiques Chirurgicales, Chirurgie Vasculaire 43027. 15. VAYSSAIRAT M, DEBURE C, CORMIER JM, et al. Hypothenar hammer syndrome: seventeen cases with long term follow up. J Vasc Surg 1987:6:838-843. 16. VON ROSEN S. Ein fall yon thrombose in der arteria ulnaris nach einwizkung von stumpfer gevalt. Acta Chir Scand 1934;73:500-506, 17. HERNDON W, HERSHEY S, LAMBDIN C. Thrombosis of the ulnar artery in the hand. JBJS 1975;57 A:994-995. 18. PINEDA CJ, WEISMAN MH, BOOKSTEIN JJ, et al. Hypothenar hammar syndrome: forms of reversible Raynaud's phenomenon. Am J Med 1985;79:561-570.